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FOR OFFICE USE, Y'l <br /> ------------------- ------------ APPLICATION FOR SANITATION' PERMIT_11� <br /> (Complete in Triplicate) Permit No. <br /> ---- ------------------- ----------------- -------------- <br /> --------------------------------------------------------- This Permit Expires I Yiar From Date Issued 6, -Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in complicince with County Ordinance No. 549 and existing Rules and Regulations:. <br /> JOB ADDRESS/kOCATION <br /> -----------we,+"_44.,e�—------------------ -----CENSUS. TRACT ------ ------------------ <br /> Owner's Name' rn 67 <br /> -------------------------------------------- -------Phone,,- <br /> /�-----------------------------I--------- <br /> ---------------- <br /> Address ---- <br /> --------------- ---------------4- --.=-City--- - ---------------- --- --- <br /> - ---------------------------- <br /> Contractor's Name --- <br /> 2-C <br /> ---------- . - !___,JJ, <br /> ----------- ---------------------License _-7-IS3 <br /> ----- Phoned------------- ----------- <br /> Commerci OTra 0e�r-Court <br /> partment House. <br /> Residence al <br /> Installation wilfterve: esi <br /> Motel <br /> -E].Other ----------------------------------- <br /> J. <br /> Number of living un <br /> V Lo <br /> its:- ------ Number of beddloms -',7 -Garba Grinder/ t Size, ------------------------- ------------------ <br /> ystem and name -----------L -------- ----- --- <br /> 4.� - I �f--------:---- ❑ <br /> - <br /> Water Supply. Public S -------Private <br /> Sili--- <br /> t. and <br /> Character of soil;to a Jepffil of 3 feet: Sand'[:] Silt. Clay 1:1----Pe6i y Loam -E] Clay Loom 1] <br /> *4 7 Hardpan 0 Adobe J'Fill Mateiial If-yes,'type ----------------- ---------- <br /> _7 7 _7 _-. F <br /> (Plot plan, showing size 8f lot, location of system in relation to' wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted' if public sewe?is available within 200 feet;! <br /> et <br /> e <br /> PACKAGE fR EAtM ENT--[-] <br /> - —SEPTIC TANK I Size-----------'------------- ------- ------------ Liquid Depth -------.----:------------ <br /> Capacity <br /> ------ Type -------------------- Material-- No. Compartments' <br /> f----------- ------------- <br /> try <br /> Distance to nearest. Well ------------------------------------Founda' tion ----------:- ------ Prop.line-------------- <br /> LEACHING- <br /> VNE No. of-Lines---------L--------------- Length of each line___________________._____- Totdh length ------------ -------- ...... <br /> 'D-Box .........7. . Type Filter Material ____________________Depth!Filter Material T_-_.________- -- -- - <br /> Distance to nearest: Well -----------------I------ Foundation ... --------- Property Line_',.---------_.--------_ <br /> SEEPAGE PIT Depth --------- r------- ci <br /> Rock Filled Yes NaN <br /> Water Table Depth ------------------------------------------------Rock Size L.........��- <br /> Distance to nearest: Well _---------------------------------------Foundation ---------------------- Prop-. Line ---------- ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- <br /> - ------- ------------- Date L------- <br /> Septic Tank (Specify Requirements) --------------------- =-------- ----- ----------- ----------- - ---------- <br /> Disposal. Fied '(Seecify Re <br /> quiremeNs)', ---------- ------------------- ----------------- <br /> --✓--------- ______L ------------------------------------------- ----------- --- ---------------2-------- ---------I---------- ------------- <br /> ---------------- I -; <br /> ---------------- ----- ----------------------------- ------------ <br /> ------------------------------------------------�L--------------- ------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the Work. will be done in, accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HealthDistrict. Home owner-or-- <br /> licen- <br /> sed agents signature�c-e�r-tifii's'the-foll0Wfif9-- <br /> "I certify that in the performance of the work for which this permit is, issued, I shall not employ any person in such manner <br /> as to become subject to Woikman's Compensation laws of California." <br /> L <br /> Signed --------------- -----------�1!---------- <br /> igne - ---- ---- ----------------------------------------------- Owner <br /> ------ ------ <br /> a ---- - ------------ <br /> yBy ------------- <br /> /6 ----------- ----------------- ........ <br /> (1 _J4 Title ........Dr�A <br /> (I fher than owner)� <br /> r FOR .DEPARTMENT USE ONLY 4 <br /> APPLICATION ON A C E BY . ... <br /> PPLICATION ACCEPTED BY ---- ------------------- -- ---- DA ------- <br /> r,,. �I PERMIT <br /> � n�_ <br /> BUILDING PERMIT ISSUED ------------------------ ------------------�f_ ---------------------------------------�DATE ------ - ------------------------------- <br /> .... ----- ------- ----------------- rDATE COMMENTS <br /> -------------------------- -------------I------------------- ------------------------------------------------------------------------------------------------------------------------------ -------------- <br /> ---------------------- ----- - -- --------------------I--- <br /> ---// ------ --- <br /> ----------------------------- -- ---- <br /> --------------------------------------------------------- - ------ ------ <br /> ------------------------------- <br /> Final Inspection by: ------ -- -------- ----- ------------ -------- Dat-e- ------ - <br /> ------ <br /> N JOA IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />